Fabrizio Cardin

Chronic mesenteric ischaemia (CMI) has a long asymptomatic period, but little is known about the clinical implications of this phase of the disease, particularly in the elderly, who are most exposed to the condition. The aim of the present observational study was to survey the in-hospital clinical course of elderly patients during the non-specific phase of the disease due to occlusion of at least one splanchnic artery. For a median of 29 months, we followed up 85 patients aged 65 and over who, for various clinical reasons, had undergone computed tomographic and magnetic resonance angiography during 2010 at Padua Teaching Hospital, assessing economic impact and reasons for admission. Thirty-four of these patients had at least one occluded artery, and 68 % of them had at least one hospital admission. Elderly CMI patients were characterised by a higher number of admissions (median 2 vs 1 p = 0.05) and a higher cost (6044 vs 1733 Euros p = 0.04), but did not present typical gastrointestinal symptoms. The higher number of hospital admissions was not due to specific clinical risks (admitting wards: general medicine: 32 vs 29 %, p = 0.77; general surgery 8 vs 14 %, p = 0.73; vascular surgery: 26.5 vs 20 %, p = 0.46). In the asymptomatic phase of CMI, hospitalised elderly patients with at least one occluded splanchnic artery can be subject to a more challenging in-hospital clinical course.

Background/Aim: Increased demand for colon cancer screening procedures can significantly impact on routine colonoscopy management at dedicated facilities, prompting a review of the factors that can negatively affect workflow. Although potential adverse effects and impact on costs of deep sedation have been documented elsewhere, this study focuses on variables that can influence performance of colonoscopy in deep sedation and interfere with normal procedure scheduling in settings where the presence of an anesthesiologist is mandatory. Patients and Methods: We performed a cross-sectional study of the activities of a colonoscopy screening unit, applying Bayesian Network (BN) analysis, designed to assess interdependencies among variables that can affect a process in complex, multidimensional systems. The study was performed at a teaching hospital where endoscopists and anesthesiologists of varying work experience operate on a rota basis. During a six-month period, we analyzed 1485 consecutive colonoscopies performed under deep propofol sedation, administered by an anesthesiologist via hand-controlled syringe. The BN was constructed with the variables: Gender, age, ASA status, bowel preparation, baseline blood pressure, endoscopist's experience, anesthesiologist's experience, presence of polypectomy, and the target node, "challenging procedure." This previously undefined category refers to any events disrupting the scheduled rota. Result and Conclusion: Two distinct networks were identified. One deals mainly with relationships among the variables, patients' demographic and clinical characteristics (procedures with polypectomy, ASA and baseline blood pressure). The other explains relationships among the variables, "challenging procedure," bowel preparation, and endoscopist's experience. The factors associated with the anesthesiologist's activity do not influence challenging colonoscopies.

Undernutrition in frail elderly people is a pathological condition that needs to be recognized and addressed early. Neurological dysphagia is among the most frequent causes of this condition in the elderly but should be considered a terminal event in Alzheimer-type dementias. Tube feeding is an important resource for facilitating metabolic recovery in cachectic patients and is particularly successful in “bridging” and stabilizing therapies prior to major treatment able to cure the patient. Clinical management of tube feeding in “incurable” conditions is complex and becomes part of the palliative care and comfort provided in the terminal stages of illness. Non-specialized physicians are often unfamiliar with the theory and practice of end-of-life interventions, and the resulting decisions are in many cases actually contrary to patient comfort. These problems deserve to be more carefully addressed when the patient is unable to cooperate or express his/her preferences and needs. The success of percutaneous endoscopic gastrostomy has led to increasingly frequent referrals for placement in critically ill elderly patients. Endoscopists therefore become a key figure in stimulating rational, correct treatment of these patients.

This work investigates the prognostic role of advanced age as a risk factor for recurrence in a population of patients undergoing surgery for N0 stage colon cancer, and also evaluates whether that role is affected by tumor location. A population of 129 consecutive patients who underwent radical surgery for N0 stage colon cancer was selected. Patients were subdivided into three age groups: 80. The only correlation found in the examined population between age and clinical-pathological features was between advanced age (>80) and tumor location in the right side of the colon. Overall survival (OS) and disease- free survival (DFS) were significantly lower in patients over 80 than in the other two classes. Two multivariate analyses were carried out: when tumor location was not considered, age >80 represented a negative prognostic factor for risk of recurrence, regardless of the other factors examined. This role was also confirmed when tumor location was considered. As hypothesized by several authors, the role of advanced age which emerges from this study is mainly due to the increased fragility of elderly patients caused by multiple pathophysiological factors, but it does not necessarily represent an absolute contraindication to surgery. The role played by tumor location remains controversial, as more and more studies show that right colon cancer (RCC) is a biological entity distinct from left colon cancer (LCC). Further studies are required to examine right and left colon cancers as two separate diseases.

Complications after surgical treatment of diverticulitis are not very frequent, in view of the total number of patients affected by this pathology, but they do become significant in absolute terms because of the high prevalence of the disease itself. Surgeons continue to debate which option is better: Hartmann resection or combined resection and anastomosis. Since age is a crucial factor when surgery is being considered, we evaluated the outcome of surgical treatment for diverticulitis in patients treated in our unit over a six-month period, in view of the number of elderly patients generally admitted. Between January 2001 and June 2012, 77 patients underwent surgery for diverticular disease in the Geriatric Surgery Unit of the Department of Surgical and Gastroenterological Sciences, University of Padova Hospital. Gastrointestinal resection and anastomosis were performed in 75 patients (97%), resulting in an overall complication rate of 37% and a mortality rate of 1%. This surgical strategy was chosen because, when it is performed by experienced surgeons, it offers the same results in terms of mortality and morbidity as Hartmann resection, while presenting significant advantages as regards the patient's quality of life. Various factors such as the timing of surgery, severity of the disease defined according to the Hinchey classification, patient's clinical condition, and surgeon's experience and expertise can all influence the surgical choice. Several studies in the literature confirm that combined resection and anastomosis is safe and efficacious, but more research is needed to confirm these data.

Colonoscopy in the elderly is a reliable practice of great diagnostic and management value. However, patient's age has long been considered to affect the success of the procedure, achieved when the cecum is intubated, there is a good view of the colon if preparation has been properly carried out, and the examination does not cause excessive discomfort or complications. Substantial improvements have been made to the latter two aspects, due to more widespread use of deep sedation with propofol and cardiocirculatory monitoring during the procedure. The aim of our work was to assess whether, in the everyday practice of an open-access, digestive endoscopy teaching center, staffed by various providers delivering screening for polyposis, age is still a limitation to the success of the procedure and whether appropriate measures have been taken to improve colonoscopy in geriatric patients. We analysed 1480 consecutive colonoscopies, of which 319 were performed in patients aged over 73 years. The examination was significantly less successful in this group of patients (88.1 vs 94.4, p=0.0001), but there were no major technical or use-related complications connected with administration of propofol for sedation purposes, despite lower doses to the elderly (2.2 ± 1.1 mg/kg total dose, mean 151 ± 72.4 mg vs 2.9 ± 1.3 mg/kg total dose, mean 199 ± 77.9 mg in younger patients, p<0.001). More experienced technical staff were not allocated to these colonoscopies (for endoscopic or anesthesiological purposes) and, according to the results of multivariate stepwise logistic regression analysis, inadequate preparation was the main factor affecting the success of the procedure in elderly patients (OR 5.9, 95% CI 2.25-15.72; p=0.0003). Only body weight over 60 kg facilitated it (weight ≥ 60 kg, OR 0.46, 95% CI 0.26-0.83). In colonoscopy in the elderly, safety appears to be the primary concern and, good outcomes can be achieved, but sometimes at the expense of diagnostic accuracy. This could probably be improved through better pre- and post-procedure care, not currently differentiated between young and elderly patients.

The authors describe the nationwide scale of suicides among the elderly in Italy for the period 1993-2010. The data are derived from the Italian Institute for Statistics (ISTAT) and the World Health Organization (WHO). The elderly turned out to represent the highest risk category for suicide, with risk increasing with age (suicide rates, per 100,000, in men aged 75 or over and aged 65-74 were respectively 28.3 and 15.7 in 2007). The rates for men were three times higher than those for women. The north-east and north-west regions of Italy had the highest rates of suicide in the elderly. Education was inversely related to the risk of suicide. Hanging was the most frequent method of suicide in men, and precipitation in women. The reasons for suicide, as inferred from available data, were predominantly mental-physical illnesses. The risk factors emerging from our analysis are discussed from the preventive point of view, in relation to the Italian situation and a review of the literature.

Congestive heart failure (CHF) is characterized by high levels of B-type natriuretic peptide (BNP), expanded total body water (TBW) and extracellular water (ECW). Bioelectrical impedance analysis (BIA) has demonstrated high diagnostic accuracy in CHF but no information is available for older patients. We hypothesized that, in the follow-up of patients with CHF, body fluid changes estimated by BIA are related to BNP variations rather than with body weight. The aim of this study was to evaluate the relationship between variations in body fluid compartments, body weight and BNP in hospitalized elderly patients with decompensated CHF. 49 elderly patients admitted to the Geriatric Department for decompensated CHF were included in the study. On admission and at discharge, all patients underwent clinical and functional assessment and BNP dosage. TBW and ECW were also determined by the BIA method. At discharge, all patients showed reductions in TBW (ΔTBW -2.9 ± 3.0 liters), ECW (ΔECW 1.9 ± 2.1 liters) and BNP levels (ΔBNP -219.6 ± 458.1 pg/mL). Variations in TBW and ECW were correlated with BNP changes (r=0.65 and 0.62, respectively) rather than with body weight variations and BNP changes (r=0.51). The stronger relationship between fluid variations determined by BIA and BNP changes may make BIA a useful method in the follow-up of decompensated CHF elderly patients.